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In short, Medicare does cover mental health services. In this article we explain to you what specific services are covered and we share some of the limitations of Medicare's mental health coverage.
Most people in America enroll in Medicare when it becomes available to them. Before Medicare was passed in 1965, 54 percent of elders aged 65 and over had health insurance. Now, 98.4 percent of elders in America have health insurance through Medicare. Many people are aware that Medicare extensively covers inpatient and hospital-based services but aren't as sure about what outpatient services it covers.
Several recent changes to Medicare's mental health coverage have also left many consumers uncertain or misinformed about what services their insurance plan will cover. This article will review what mental health services Medicare currently covers and what it may cover in the future if pending laws get passed.
Medicare was passed in 1965 to increase access to healthcare for America's senior citizens. People who work pay into Medicare during their working years through a payroll tax, then are eligible to enroll when they turn 65 years old. Medicare also covers people younger than 65 when they have disabilities. People with end-stage renal disease or Lou Gehrig's disease can immediately enroll in Medicare before they turn 65 years old. People who otherwise qualify for Social Security Disability Income (SSDI) are eligible for Medicare 24 months after they start receiving SSDI. People can inquire about Medicare eligibility at their local Social Security office.
Medicare Part A covers inpatient treatment and Medicare Part B covers outpatient treatment. These two components of Medicare are often called "Original Medicare." People can sign up for a Medicare Advantage Plan, also called Medicare Part C, when they want additional or different coverage. These plans are offered through private insurance companies. Medicare Part D is the plan that covers prescription drugs. It is also administered by private insurance companies and is an optional branch of Medicare that was created by the 2003 Medicare Modernization Act.
Medicare Part A covers inpatient mental health care including the following services:
Every time someone who has Medicare is admitted to the hospital, it triggers the start of a Medicare benefit period. That period ends after the person has not had inpatient care for 60 days in a row. There is a deductible for each benefit period. The deductible amount for 2019 is $1364. There is no coinsurance for the first 60 days of inpatient care, but after that period, people must pay increasing amounts of coinsurance for each day they remain in care.
There is no limit to the number of benefit periods a person can receive for inpatient medical care or for inpatient mental health care received in a general hospital. This includes care in a psychiatric unit of a general hospital. However, Medicare places a strict limit on care received in a psychiatric facility. Medicare imposes a lifetime limit of 190 days for Inpatient treatment in a psychiatric hospital.
Mental health advocacy groups like the National Alliance on Mental Illness (NAMI) are actively lobbying to change this policy that unfairly limits mental health care. Many laws have already been passed in the last decade to remove disparities between mental health and medical coverage in both private and public insurance plans, and more are being introduced.
Medicare Part B covers outpatient mental health care including the following services:
Medicare Part B has an annual deductible that changes over time. It was $134 in 2018 and will be $135.50 in 2019. After the deductible, Medicare covers 80% of outpatient services, leaving people to pay a 20% coinsurance on the Medicare-approved amount for that service.
To see the specific medicare mental health providers near you, visit Physician Compare or call 1-800-MEDICARE.
There are limitations on the kind of therapy that Medicare will cover. First, Medicare restricts coverage to therapy provided by specific types of providers. Covered provider types include:
Professionals in any of these categories can choose to opt out of Medicare reimbursement, meaning that the only way to see them when you have Medicare is to use a supplemental plan or to pay out of pocket for their services. If you want to pay for therapy using Medicare, check with the provider first to confirm that they have not opted out of accepting Medicare and are a participating or non-participating provider. Psychiatrists often choose to opt out of Medicare.
Participating providers accept Medicare and always accept Medicare's approved amount for their services. They submit a bill to Medicare for your care and you are responsible to pay 20% of that amount. Non-participating providers accept Medicare but choose whether to accept Medicare's approved amount for services on a case-by-case basis. They can charge up to 15% more than Medicare approves. This means you need to pay as much as 35% coinsurance when you see a non-participating provider.
Some states limit how much non-participating providers can charge above the Medicare-approved amount. For example, New York limits that amount to 5%. Some Medicare supplement plans, including Medigap Plans F and G, cover these excess charges.
Medicare has only recently started covering services provided by licensed professional counselors (LPCs) and marriage and family therapists (MFTs). Due to provisions in the 2018 Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, LPCs and MFTs can be reimbursed by Medicare for therapy provided to people with a primary substance use disorder diagnosis starting on July 1, 2019. This includes treatment for co-occurring mental health conditions. Professional advocates are lobbing for LPCs and MFTs to be covered for mental health services beyond this special case.
Medicare only covers services linked to a primary psychiatric diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Medicare has only started reimbursing marriage and family therapists starting in 2019, and only for services for people with a primary substance use disorder diagnosis. It won't cover any kind of marriage or family therapy from any kind of provider if it isn't required to treat a mental health condition. This means that if you want to see a social worker or psychologist to address communication or other relationship issues that aren't directly related to a mental health diagnosis, Medicare won't cover it.
Medicare has historically placed strict limits on coverage for "telehealth services" including online medical or mental health services provided via videoconferencing technology. Until recently, Medicare only covered telehealth services provided in rural locations in federally designated Professional Shortage Areas or outside of Metropolitan Statistical Areas. Medicare would also only cover rural telehealth services when they were provided in a medical facility like a hospital or clinic, ruling out in-home telehealth services like online counseling.
Fortunately, this is starting to change. In addition to extending Medicare reimbursement to LPCs and MFTs who provide counseling services to people with substance use disorders, the 2018 SUPPORT Act extended coverage of telehealth services to include in-home services. Starting on July 1, 2019, in-home telehealth services will be covered by Medicare, even for people living outside of designated rural areas. However, the SUPPORT Act only authorized these changes for people needing substance use disorder treatment.
Lawmakers want to close this gap. United States Representatives Suzan DelBene (WA) and Tom Reed (NY) reintroduced the Mental Health Telemedicine Expansion Act (HR 1301) to Congress in February 2019. If passed, the bill would expand the list of originating sites for all telemental health services to include patients' homes. This means that in the near future, Medicare may start covering online counseling services from a covered provider type for a covered diagnosis.
Unfortunately, there are few options for getting Medicare to cover unauthorized services other than changing the federal policies that govern Medicare. Advocacy can make a difference. The 2008 Patients and Providers Act changed the unfair Medicare policy that made people pay 50% coinsurance for outpatient mental health services. It slowly lowered the coinsurance rate over time until it came into parity with the 20% coinsurance for outpatient medical services in 2014.
Due to how frequently psychiatrists opt out of Medicare, many people ultimately have no choice but to see one who doesn't accept Medicare. Sometimes, signing up for a Medicare Advantage plan (Medicare Part C) expands access to therapists and psychiatrists who don't accept Medicare but who accept insurance from the private insurance company that governs the Medicare Advantage plan.
Many people who want a service that isn't covered by Medicare, like marriage counseling, or who want to see a specific provider who doesn't accept Medicare, choose to pay out of pocket for these services. Other people choose alternative services or providers that are covered by Medicare. If you can't find a local provider who accepts Medicare, consider searching for a provider who offers free or low-cost counseling on OpenCounseling.com, inquiring into public mental health services in your area, or signing up with an online counselor with BetterHelp (a sponsor) whose rates fit your budget. The care you need might be only a click or a phone call away.
